Personal Accident and Sickness Insurance Form

1. 1. Insured Entity Type (please select):
   Sole Trader Partnership Public Listed Company

   Unlisted Limited Company Not For Profit / Association Private Company (Pty Ltd)
2. 2. ABN:
3. 3. Insured Name:
4. 4. Trading Name (if applicable):
5. 5. Insured's Registered Address: (Place where business is registered/place of incorporation.)
6. 6. Occupation/Business Description: Please provide a detailed description of all business activities including the activities of any related entities.
7. 7. Annual revenue / Turnover for the last 12 months (AUD): If new or trading less than 12 months, please estimate annual revenue / turnover for next 12 months.
8. 8. Staff Size: Include all principals, partners, directors and employees (full time, part time and casual staff, interns and volunteers).

9. 9. Does the Insured currently have Individual Personal Accident insurance in place?
   YesNo
10. 10. After enquiry of all Partners, Principals, Directors, Officers, Trustees and Senior Managers:

    a. Have there been any claim(s) made against the Insured or any loss or expense incurred which might fall within the terms of this insurance cover?

    YesNo

    b. Have any circumstances occurred which may give rise to a claim against the Insured or result in any loss or expense incurred which might fall within the terms of this insurance cover?

    YesNo

    Incurred means any settlement made, legal fees, defence costs or reserved amounts.

    If YES to any of the above, please provide full details:

11. If YES, has the Insured incurred personal accident claims exceeding $5,000 over the past 5 years?

    YesNo

    If YES, has the Insured had 1 claim and was the total value less than $15,000?

    YesNo
12. 11. Has the Insured or any Partners, Principals, Directors, Officers, Trustees and Senior Managers ever been declined this type of insurance, or had similar insurance cancelled, or had an application for renewal declined (other than insurer exiting that area of insurance), or had special terms or restrictions imposed?
    YesNo
13. 12. Is the Insured domiciled in Australia with no subsidiaries outside Australia or New Zealand?
    YesNo

    If YES, proceed to question 13. If NO, please confirm the following:

    a. Is the Insured domiciled in Australia?

    YesNo

    b. Where are the Insured's overseas subsidiaries?

    Please specify below in which countries the Insured's subsidiaries are located and indicate the percentage of total revenue derived.

    Subsidiary Name	Country	Revenue %

14. 13. What is the Insured's breakdown of turnover?

    This information is used to apportion the payment of stamp duty across different states and territories where the Insured operates.

    NSW %	ACT %	QLD %	VIC %	TAS %	SA %	WA %	NT %	O/S %	Total
    									100%

15. 14. Is the Insured exempt from GST?
    YesNo
16. 15. Is the Insured exempt from Stamp Duty?

    If NO, continue to question 16. If YES, please confirm that the exemption applies to the insured.

    YesNo

    a. NSW Small Business Exemption

    I declare that the Insured is a small business and qualifies for the NSW small business stamp duty exemption in relation to this policy...

    YesNo

    b. Other Exemption

    I declare that the Insured is relying on a stamp duty exemption (for example a charity organisation exemption) in relation to this policy...

    YesNo

16. 16. Insured Person:
17. 17. Date of Birth:
18. 18. Occupation: Please state the position that the Insured holds within the company.
19. 19. Please select scope of cover:
    24 hoursWorking hours onlyOutside working hours
20. 20. Would the Insured like to include any Optional Extensions for an additional premium, or any Additional Exclusions for discounted premium? If YES, please select the Optional Extensions or Additional Exclusions below.

    a. Lump Sum Benefits for Fractured Bones and Dental Benefits - $90 (plus charges) additional premium:

    YesNo

    Includes a lump sum benefit for injury resulting in broken bones up to $3,000 and loss or damage to teeth up to $1,000.

    b. Funeral Benefit - additional 5% premium:

    YesNo

    c. Modification Benefit - additional 5% premium (available for under 65 years only):

    YesNo

    d. Motorcycling Exclusion - 5% premium discount:

    YesNo

    e. Sporting Activities Exclusion - 5% premium discount:

    YesNo
21. 21. Please confirm your requested Schedule of Benefits:

    Benefit	Example amount per Insured Person	Required Amount (please specify)
    Accidental Death and Disablement	$100,000	$
    Weekly Injury Benefit	$1,000	$

    
    

    Benefit Period (weeks)	104 weeks	weeks
    Excess Period (days)	7 days	days

    Weekly Sickness Benefit

    Weekly Sickness Benefit	$1,000	$
    Benefit Period (weeks)	104 weeks	weeks
    Excess Period (days)	7 days	days

    Optional Benefits (if applicable)

    Fractured Bones Benefit - Injury	$3,000	$
    Dental Benefits - Injury	$1,000	$
    Funeral Expenses	$10,000	$
    Modification Expenses	$10,000	$

    The maximum weekly benefit period for Insured Persons over the age of 65 is 52 weeks. Note: subject to underwriting criteria.

Signing this Proposal Form does not bind the proposer or the Insurer to complete this insurance.

The undersigned declares that the statement and particulars in this Proposal Form are true and that no material facts have been misstated or suppressed after enquiry. The undersigned agree that should any of the information given by us alter between the date of this proposal and the inception date of the insurance to which this proposal relates, the undersigned will give immediate notice thereof.

The undersigned acknowledges that they have read the Important Notices in this Proposal Form, the Product Disclosure Statement, policy wording and associated endorsements and are satisfied with the coverage provided, including the limitations and restrictions on coverage. The undersigned agrees that this Proposal, together with any other information supplied by us shall form the basis of any contract of insurance effected thereon.

To be signed by the Insured for whom this insurance is intended for

It is important the undersigned of the declaration above is fully aware of the scope of this insurance so that these questions can be answered correctly. If in doubt, please contact the broker or agent, since non disclosure may affect an Insured's right of recovery under the policy.